Affordable Care for Children: One Pediatrician’s Experience

Covering children until they are 26 years old, not excluding patients for pre-existing conditions and expansion of Medicaid coverage for all are three tremendous improvements to healthcare over the last 5 years. However, the hurdles have been numerous. Many independent private practices like ours are closing because they cannot make ends meet. More physicians are retiring early and as a result the shortage of primary care physicians is growing. After reading Dr. Jellinek’s article, I realize we are not alone in our financial struggle to stay afloat. What has changed?

Below are three experiences in this new era of “affordable care” showing there is plenty of room for improvement.

“You have been excluded from the Health Care Exchange plan because you have privileges at Children’s Hospital.” Huh?

I was not listed on the health care plan patients purchased because I was on the medical staff at The Children’s Hospital. This fact was not clear when families signed up online. This did not make any sense. Why would an insurance plan exclude a community pediatrician on staff at one of the top Pediatric Hospitals in the country? It was so surprising, our small local newspaper wrote an article about it too.

The liaison at the insurance company confirmed the information was true. Only pediatricians NOT on staff at The Children’s Hospital were considered ‘in-network’ on two plans designed to save consumers money. At what cost? “What happens if a child is diagnosed with leukemia and needs pediatric specialty care?” The liaison answered the family would be responsible for payment if this rare event occurred. Talk about reading the fine print! “Leukemia is not that common, after all”, she said. Let’s hope not ma’am.

“I am sorry; a prior authorization is required to order a chest x-ray on your patient.”

A sick 2 year old girl was sitting in front of me with a 3 day history of fever to 104 degrees. She had been coughing and had crackles in her lungs. Ordering a chest x-ray to confirm diagnosis of pneumonia has been standard of care for the past 60 years. Cost of an x-ray is approximately $50. Obtaining prior authorizations for MRI or CT scans is common, but a chest x-ray? Do you know how long a prior authorization for Medicaid insurance takes? More than an hour on the phone and approval is not guaranteed. I was forced to refer them to the ER for care. The final diagnosis was indeed pneumonia and the ER bill was over $5000. My bill would have been $100 + the cost of chest x-ray. Affordable care, for whom exactly?

“The family decided not to pay their insurance premium, so the company is taking back $3000.”

The most dreadful part of Affordable Care are the “take-backs.” Exchange health plans offer a 90 day ‘grace period’ for patients to pay premiums or terminate coverage. During this period, they see their doctor and we are paid for care we provide. Three months to 2 years later, we receive notice the patients did not pay their premiums and insurance will take back thousands of dollars already paid to us for care. They deduct the money from funds they owe us for other patients to make up the difference. You would think that is illegal? No, it is big business. We are forced to bill the families directly and rarely receive reimbursement.

Is there any other occupation where you go to work, were paid for your labor, used those funds to buy groceries, pay your mortgage, childcare bills, and student loan payments, then without warning, 3 months to 2 years later, that money is taken out of your next paycheck?

Compensation at the “Big 5” ranged from $10.1 million for Humana’s CEO to more than $66 million for the CEO of United Healthcare in 2015. CEO compensation for Anthem, Aetna, and Cigna also fell within that range. Affordable health care has definitely helped people. But who exactly are we trying to help? I am not convinced it is the children growing up in America today.

The biggest dilemma is the anticipated shortfall of primary care physicians in the future; estimated to be 90,000 by 2020 by the Association of Medical Colleges. I have four children sleeping in one bedroom and drive a five year old minivan. I live comfortably and have no complaints. What concerns me most is whether or not this lifestyle will entice bright, altruistic young people to become physicians in the future? Or will they become CEO’s of health insurance companies or hospitals instead? I am afraid of the answer. EVERY child, no matter their age, race, or medical condition deserves access to quality health care. Who will be left in health care to provide it?

Comments

“I am afraid of the answer. EVERY child, no matter their age, race, or medical condition deserves access to quality health care. Who will be left in health care to provide it?”
According to the Affordable Care Act ,ie: Obama plan…..ARNP and PA…. the future is bright !!! . We will be replaced

I stopped taking the last CMO for Medicaid in Georgia recently becaused they started pulling the same shenanigans that the others had before them. I now only take straight medicaid and on a case by case basis decide who gets free care based on their need.

Over three decades my attitude has shifted from “its a decent and good thiing to help people on medicaid” to everyone including patients, hospitals, CMOs, and state Medicaid programs, are gaming the system. The physician is the one that looses financially. Best of luck to those of you who work day to day trying to see a medicaid patient in three minutes just to stay afloat financially.

We don’t take anything about any of the government programs, Medicaid or Obamacare, as griff. As then governer Bill Clinton replied back to me about a medicaid payment denial for all the $1500 worth of care I gave for a premie in our local hospital while not seeing patients in the office one day: “These charges were denied appropriately.”

Huh? I’m not playing the new games. I’ll leave medicine before I get walked on and abused like so much driftwood. For those who are wearing blinders, you need to get off the ship. Its sinking!

I have a solo practice in Oklahoma. We take no Medicaid other than special circumstances. The powers that be prey on our love of children. ” How can you not help the children” etc. If the office closes no children are helped. I have children and bills to pay. A business has to make business decisions. We should not be guilted into bankruptcy.

We as physicians get treated like dirt because we allow ourselves to be treated like dirt. We accept insurance contracts that we should not accept. We don’t hold insurance companies and the government accountable for what they owe us. Our professional organizations are more interested in extorting money from us for dues, CMEs, maintainance of certification, and board exam fees than having legal advice on which contracts we should sign or suing insurance companies when they obviously shaft a physician. If the AAP or the AAFP had a legal arm that prosecuted insurers for obvious contract malfeasance, physicians would worry less about the books and more about the patients.

You are right on. We need to stand up together and break the rules. Not allow ourselves to be treated like dirt. Many are obviously fed up or afraid. Fighting back, whether MOC or MACRA, will take large numbers to stand up together and refuse to follow rules and comply. Thank you for your comments. I agree completely.

Incisive point you make about the “take backs” from Obamacare exchange plans. A patient has a 90day grace period for to pay their monthly premiums, but if care is rendered in the last 60 days of that grace period, the physician will not be paid for that work. The insurance co may pay for the work initially, but then collect it back months or even years later.

This wasn’t revealed in the beginning, you had to dig and dig and read online because no information was ever given to any physician about how this all would function in practice. How could it, since the bureaucrats themselves didn’t have a clue?

Try collecting after the point-of-care from a patient in todays’ crappy economy and where families are stretched to the limit. Precisely the reason my practice decided early on as a business decision to NOT accept any Obamacare exchange plans. It’s funny money that you cannot count on to pay for the expanding overhead of any business. It is an abomination and I am thoroughly disgusted at how physicians are the punching bag in all of this healthcare mess. I have a sign posted prominently in the waiting room that preauthorizations are not free. One hour on the phone? What physician can do that and survive?

Thank you for your comments. I, too charge for prior authorizations based on time. However, I took a beating over on KevinMD from commenters on this point. They say it is against contract, however I consider it a non-covered service. What do you do?

I pored through my contract and there’s nothing on charging administrative fees for ancillary/preauthorization services. In fact, I only have 1 contract, everything else is out of network. So it’s easy administratively for us to implement. There are many times we get pharmacy requests for preauthorizations and the local pharmacists now know me and what I’m apt to do, I include a bright yellow form stapled to the prescription essentially saying “This is the best Rx my medical decision making has determined for your medical care. Preauthorizations set by your pharmacy benefit plan require time and conference calls, and are $X extra and payable via credit card.” The extra running around that the preauthorizations impose on a practice are a nightmare and cannot just be assumed at $0 cost. There is a cost to having a staff person running (or the physician) around doing this and not using the time to order supplies, stock a room, prep a patient or clean the room. We must think like a business, not like a church (and even they think like a business! 😉

Any chance I could get a copy of that wonderful bright yellow form? I would be happy to send you my email address if you wouldn’t mind. I would LOVE to do the same thing. Agreed, that our practice would not be solvent if we did them for free.